IPhysiotherapy Course of the University
for the State and the Pantanal Region Development - UNIDERP - Campo Grande/MSIIDepartment of Biomechanics, Medicine and Rehabilitation of the
locomotor System - Ribeirão Preto Medical School - FMRP-USP

Edema's measurements on ankle injuries are necessary
as part of the evaluation and diagnostic check. The present study was designed
to analyze the Figure-of-Eight method and volumetry measurements and check their
intratest and intertest reliability. Twenty asymptomatic healthy male volunteers
from 15 to 30 years of age, were randomly examined by three clinical examiners.
Each examiner performed three measurements following each method. It was used
standardized positioning and measurement techniques. The results showed reliability
in both methods (ICC = 0.99). The Pearson product-moment correlation coefficients
showed reproduction between examiners, where values of r = 0.91, r = 0.95 and
r = 0.96, respectively were found. These findings suggest the Figure-of-Eight
method and volumetry are reliable measurements.

Ankle lesions resulting from traumas are frequent
during sportive practices, many times dismissing the athlete from competitions.
Most of these lesions result in acute inflammatory process in which the edema
is one of the most relevant symptoms(1-4).

The presence of edema indicates tissue inflammatory
reaction, alteration on the capillaries normal dynamics and inadequate or hindered
functioning of the venous pumping and the lymphatic system(5,6).

It is a process indicated by liquid excess in
the interstice or in serous cavities, being unchained by histamine, bradicinine,
leukotrienes and other classes of chemical mediators that may correspond to
an exudates or transudate. The exudate is the extravascular inflammatory liquid
with high protein concentration and high amount of cellular residues; on the
other hand, the transudate is a liquid with low protein content mostly composed
by albumin(7,8).

Petersen et al.(9) classified
the ankle edema through visual method as: light, moderate and severe. The light
edema occurs when all bone marks (malleolus, navicular bone and the base of
the fifth metatarsus) are well visible; the moderate edema is verified when
the bone marks are less visible and the severe, when the bone marks present
difficult visualization.

Gabriel et al.(10) report that,
in case the edema is not corrected, it will lead to a functional incapacity
state due to the limitation on the muscular elasticity, decrease on the articular
arcs, aponeurosis shortening and, in some cases, tissue necrosis.

With association of edema measurement methods,
it is possible to evaluate the lesion seriousness and the treatment effectiveness
and several methods are used to measure the limbs volume, among them: circumference
measurement, volumetry, bioelectronic impedance and computational model(9,11,12).

The Figure-of-Eight method and the volumetry
are the standardized evaluation processes most used for ankle edema measurement
with the objective of quantifying treatment efficiency(5,11-15).

Since the age of Archimedes, the water displacement
has been used to measure the body mass and literature reports indicate that
is has been useful to distinguish gold from other metals for the creation of
the Hiero King(5,12).

Volumetry is important technique to measure articular
edema in uneven surfaces such as foot and ankle. The measurement is performed
with the volumeter, a translucent recipient specially designed, containing water
inside and with a gutter for the outflow of this liquid(12,14-17).

The Figure-of-Eight method, developed by Esterson(18)
consists of the perimetry with tape measure of the areas of higher ankle edema
concentration, in other words, the region of the anterior talofibular, calcaneofibular
and anterior tibiofibular ligaments(11).

Mawdsley et al.(13) determined
that the Figure-of-Eight method presents reliability based on the Intraclass
Correlation Coefficient, however, its validity in relation to the volumetry
method was not yet determined.

Thus, the present study was designed to analyze
the Figure-of-Eight method and volumetry measurements and check their intratest
and intertest reliability.

CASUISTIC AND METHODS

Sample

Twenty male volunteers with ages ranging from
15 to 30 years (
= 21.8) with no trauma history were recruited through verbal invitation. The
volunteers who presented previous trauma-orthopedic dysfunctions (fractures,
tendinopathies), previous surgical procedures and other systemic pathologies
were excluded from the sample selection.

Before the beginning of the experiment, all volunteers
were informed about the research's procedures and signed an Informed Free Consent
Form, according to the Norms and Guidelines of Researches involving Human Beings,
according to resolution of the Health National Agency 196/96.

Procedures

Volumetric measurement

A volumeter manufactured with translucent material
(glass) was used, according to standard of the label Baseling Volumetric Edema
Set, Idyllwild, CA with the following dimensions: 33.5 cm of length, 13 cm of
width and 24 cm of height (figure 1).

Wearing adequate clothes to show legs and ankles,
the volunteers were positioned in chair maintaining left knee flexion, randomly
selected in approximately 90o. Before immersion, a water layer was
manually applied to the left lower limb (MIE) in order to minimize the amount
of air underneath the hair(15).

Following, the volunteers were instructed to
lower MIE gently into the volumeter containing five liters of water at room
temperature until foot rests comfortably at the bottom. The water volume displaced
was discharged by a gutter into a Becker flask and transferred to a 1000 mL
test tube (graduation of 10 mL).

Three clinical examiners (A, B and C) were randomly
selected for the volumetry individual collect. Each examiner performed measurements
three times in each volunteer and recorded values in standardized form.

Figure-of-Eight method

The examiners instructed the volunteers, also
randomly, to remain seated with knee in complete extension and ankle at neutral
position. The measurement was then performed with the zero of the tape measure
kept on the middle point between the articular projection of the anterior tibial
tendon and the lateral malleolus. The tape measure was guided to the center
of the foot medial longitudinal arch on the navicular bone, touching lightly
the plantar region towards the lateral malleolus, calcaneus tendon and medial
malleolus up to reaching the point zero of the tape measure (figure
2).

Each examiner performed the measurement three
times in each volunteer and recorded values in standardized from.

Statistical analysis

The analysis of variance ANOVA was applied with
the objective of comparing the averages individually and between each other.

The Pearson product-moment correlation coefficient
was calculated to measure the linear relationship degree between measures collected
through volumetry and the Figure-of-Eight method for each examiner.

For the evaluation of the methods' reliability
the F test was applied to determine the difference between variances, in other
words, to determine which method presented the lowest variation in the data
collection. Other test used to verify the collect methods' reliability was the
Intraclass Correlation Coefficient (ICC) in which values near to 1 indicate
excellent test reliability.

RESULTS

No significant difference for volumetry (p =
0.87) and for the Figure-of-Eight method (p = 0.12) was verified in the analysis
of variance ANOVA.

In relation to the Pearson product-moment correlation
coefficient, the examiners obtained similarity of results, being the lowest
variation in the collect of examiner C (table 1).

The results of the F test presented higher variability
in volumetry for 90% of the individuals (p < 0.05) and the same variability
for 10% of the individuals. In none of the individuals, the volumetry variability
was lower if compared with the Figure-of-Eight method.

The set of data after statistical treatment showed
the presence of lower variability in data collected by examiners in the Figure-of-Eight
method (graphic 1) and the ICC result of 0.99 for both
measurement methods corroborates the reliability of both methods.

DISCUSSION

The validation of the results was based on the
sample's homogeneity, composed of male young adults with average age of 21.8
years, values that corroborate with data found in literature(9,13,19-31).

The results indicate that both methods are reliable
in the ankle edema measurement, and it is presumed that these results are due
to the standardization of the measurements.

It is believed that the volumetry presented higher
variability in the F test due to the instability of the liquid mean, once most
volunteers could not maintain the MIE still during the measurement performance.

It is supposed that the results similarity was
a result of the examiners previous training and the individual technical improvement.

According to Esterson(18) and Tatro-Adams
et al.(11), the Figure-of Eight method is a technique of easy
execution also presenting quickness, low cost and reliability and when compared
with the volumetry technique, it is also more hygienic.

However, it is presumed that the Figure-of-Eight
method should not be selected as measurement method when the edema reaches the
entire inferior extremity such as the leg, ankle and foot distal portion, being
the volumetry method the recommended technique in these cases.

Other works, comparing different measurement
methods, should be conducted for a better comparison between results in function
of the lack of works in the literature researched (Medline, Lilacs).

CONCLUSION

One concludes that the Figure-of-Eight method
and the volumetry technique present high reliability and easy clinical applicability
in the measurement of the ankle joint volume.